Complications - Lichtenstein Repair of Inguinal Hernia

Irritation, entrapment and injury of the inguinal nerves with persistent postoperative pain (ilioinguinal syndrome, genital nerve syndrome)

• The nerves were injured or divided during dissection. The particular nerves at danger are: lateral femoral cutaneous; ilioinguinal; iliohypogastric; genital and femoral branches of the genitofemoral nerve.
• In iatrogenic division of these nerves they should be excised and infiltrated postoperatively with local anesthetics, since this will lower the risk of postoperative paresthesia.
• If the nerves are not divided but only irritated or touched, this may result in postoperative paresthesia which often is amenable to local anesthetics.

Injury to the spermatic duct

• How to proceed in any injury of the spermatic duct depends on the following aspects: Has the spermatic duct been divided completely or only partially? How old is the patient? Does the patient want to preserve his fertility?
• In elderly patients no longer sexually active the spermatic duct may be transected.  After the operation the patient must always be informed of what had happened and the consequences for him.

Bowel injury

• In case of accidental iatrogenic bowel injury during the procedure the lesion should be immediately closed by suture.

Injury to the femoral artery and arterial hemorrhage

• Arterial hemorrhage from the femoral artery will result in rapid massive blood loss with the clinical sequela of hypovolemic shock. The bleeding must be noted and its source oversewn,

Bladder injury

• If the bladder has been injured the lesion must be oversewn. Relieve the bladder for seven to ten days with a suprapubic catheter.

Hematoma

• Definition: Hemorrhage or secondary bleeding in or around the wound
• Clinical symptoms: Tender and discolored swelling
• Diagnostic work-up: Ultrasonography and ruling out systemic cause (such as coagulation disorders)
• Treatment: Small hematomas only need to be observed and usually do not entail any further treatment.
• Larger hematomas should undergo paracentesis or be evacuated. Massive secondary hemorrhage must be explored by revision surgery.

Seroma

• Definition: Spaces in the surgical field filled with secretions and lymph.
• Clinical symptoms: Swelling without tenderness and discoloration.
• Diagnostic work-up: Ultrasonography
• Treatment: Small postoperative seromas are absorbed by the tissue and only require follow-up. If the size of the seroma results in clinical symptoms, in rare cases this may require paracentesis (absolutely sterile conditions!). Usually, after informing the patient the seroma only needs to be followed up.  In case of recurrent seroma repeat paracentesis is not recommended, but rather insert a drain under sonographic guidance and leave in place for several days. This also applies to those rare cases where the seroma results in an infection.

Infection and secondary healing

• Definition: Wound infection by pathogens.
• Clinical symptoms: The five cardinal symptoms of infection: Calor, dolor, rubor, tumor, functio laesa.
• Treatment: Reopen and force apart the wound, cleanse extensively, and continue with open wound treatment and systemic antibiotic protocol.

Mesh infection

• Since postoperative mesh infections are frequently hard to manage by nonsurgical means, in extreme cases the mesh will have to be removed by revision surgery and the hernia defect closed without any foreign body.

Injury to the femoral vein with subsequent thrombosis

• Iatrogenic injury to the vein with subsequent thrombosis in the surgical field must be regarded as deep venous thrombosis of the pelvis.
• Diagnostic work-up: Duplex and doppler ultrasonogrpahy or phlebography
• Treatment of deep venous thrombosis of the lower extremity Compression, ambulation, full heparinization (Caution: Risk of secondary bleeding!).
• This link will take you to the International Guideline Library.

Entrapment or division of the spermatic vessels, postoperative testicular swelling

• Postoperative testicular swelling is the sequela of hypoperfusion. This may result in total loss of the testicle. Open surgery is required to improve venous drainage.

Testicular atrophy

• Definition: Irreversible epithelial injury of the seminiferous tubules with subsequent loss of spermatogenesis.
• Clinical symptoms: Initially swelling and warming, followed later on by shrinking and dyesthesia.
• Diagnostic work-up: Ultrasonography, urology consult.
• Treatment: No reasonable treatment known at this time.

Recurrence

• Definition: Inguinal hernia newly developed after previous inguinal herniorraphy.
• The clinical symptoms and diagnostic work-up correspond to that in inguinal hernia.
• Treatment: Herniorrhaphy with implanted mesh, primarily as TAPP or TEP procedure.

Overlooked bowel lesion

• Clinical symptoms: Patient does not recover from surgery, suffers from abdominal pain, nausea, guarding, and displays symptoms of peritonitis.
• Treatment: Reoperate, expose the lesion and suture it closed or resect it and perform abdominal lavage, if necessary. If peritonitis is present, institute an antibiotic protocol for at least one week.

Postoperative bowel atony

• Treatment: Administer prokinetic medication such as metoclopramide, neostigmine.

Mechanical ileus

• Clinical symptoms: Distended abdomen; gas crescents on abdominal radiographs; in case of ischemia possibly elevated lactate levels and clinical signs of transmural peritonitis
• Treatment: Revision surgery, identifying and managing the cause.